Independent investigation into the care and treatment of Mr N
LondonThis is the independent investigation report into the care and treatment of Mr N published on the 10thFebruary 2022. Mr N was in receipt of services in West London.
Recommendations (26)
Action plan published.
21 of 26 per-recommendation responses extracted from the action plan.
View action plan
1
The Trust
Accepted
Recommendation
The Trust must ensure that there is a clear system for ensuring that capacity assessments are completed and recorded where indicated.
• COMPLETED. The Trust completed a comprehensive review of the M9 policy (Mental Capacity Act) and this was re-issued October 2021. The re-issued policy clearly outlines the system in place for ensuring accurate and timely capacity assessments are completed and recorded. • IN PLACE. Capacity assessments and their outcome are recorded at the time by the clinician or social worker as part of a specific Mental Capacity Act section within our Electronic Patient Records. • IN PLACE. Where an urgent or standard authorisation is made or sought under the Trust Mental Health Deprivation of Liberty Safeguards, all documentation including the outcome is held centrally by the Head of Mental Health Law, and reported to the Care Quality Commission. • IN PLACE. Where Mental Capacity Act is used for significant care or treatment of Trust service users/patients, these are reported to the Trust Mental Health Law Committee. • IN PLACE. All staff involved in direct clinical decisions relating to capacity assessments attend mandatory Mental Capacity Act training, with a focus on assessment and recording of capacity. This is supported by bespoke training sessions. • IN PLACE. The Trust has invested in a new full-time Trust-wide role (Mental Health Act Lead) to help deliver this recommendation.
10
The Trust CAMHS
Accepted
Recommendation
The Trust CAMHS to review its approach to transferring patients and to benchmark itself against the NICE guidance on the Transition of Children and Young People, to use the findings to develop a robust patient centred approach to transfer and …
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The CAMHS service will benchmark itself against the relevant NICE guidance, and ensure a patient centred approach to transfers and discharges. • COMPLETED. A new transitions protocol was created and signed off by service line Directors in Local Services. This drives our patient-centred approach. • IN PLACE. A Task and Finish Group has been set up to implement this new policy across services. • COMPLETED. An audit was undertaken relating to compliance with the NICE guidelines, and actions are being used to inform the current 18-25 Mental Health Integrated Network Teams pathway development. • UNDERWAY. The Trust is continuing further work during 2021/22, through Children and Young People's Transformation funds focusing on age specific services for those aged 16-25.
11
The Wells Unit
Action Plan Published
Recommendation
The Wells Unit operational policy should include the expectation that all admissions make reference to the clinical rationale for the level of security.
12
The Trust
Accepted
Recommendation
The Trust must ensure that the expectations of Section 117 MHA are applied when patients are discharged from out of area CAMHS forensic admissions.
• IN PLACE. When planning for discharge clinicians consider the requirements of Chapter 33 of the Code of Practice, which deals with aftercare provisions. • IN PLACE. Where a Tribunal or hospital managers’ hearing has been arranged for a service user who might be entitled to after-care under s117 of the Act, the hospital managers ensure that the relevant Clinical Governance Group and local authority have been informed.
13
The Trust
Accepted
Recommendation
The Trust should audit current risk assessments completed in CAMHS and EIP against the Clinical Risk Policy, and then develop a plan to improve performance and quality.
To conduct an audit as part of the Trust Annual Audit Programme, of risk assessments completed in Child and Adolescent Mental Health Services and Early Intervention in Psychosis, followed by an appropriate action plan to improve performance/quality where gaps exist. • COMPLETED. Prior to the closure of the Wells Unit an Independent audit of risk assessments was completed in February 2020 and the recommendations were implemented. • COMPLETED. The Trust reviewed the C27 policy (Mental Health Clinical Risk) and re-issued it in April 2021. • IN PLACE. Audit of risk assessments is completed by senior psychologists within West London Forensic Services / Child and Adolescent Mental Health Services / Early Intervention in Psychosis. • IN PLACE. Early Intervention in Psychosis now accepts care for those aged 14+ (and younger by discussion). • IN PLACE. Risk information for Child and Adolescent Mental Health Services and Early Intervention in Psychosis patients is entered and viewed through the risk box in the Clinical Summary Portal on Electronic Patient Records. • IN PLACE. A new risk assessment process started in September 2019, making the review process more streamlined, and when risk changes or needs to be reviewed, new forms are completed. • UNDERWAY. Work is taking place to complete the development and improvement plans required by July 2022.
14
The Trust
Accepted
Recommendation
The Trust must review its CPA policy to ensure that where there are multiple agencies providing care and support to a patient the care plan identifies: • The lead agency for communication between the agencies • Information and reporting channels …
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Undertake a comprehensive review of the Trust Care Programme Approach policy to ensure the points identified in the recommendation are considered and addressed. • IN PLACE. All handovers between staff and care settings include verbal and written communication including information on medication, risk assessment, triggers, crisis management plan, service user needs and service user views. • IN PLACE. All details are recorded by the referring staff in the progress notes on Electronic Patient Records and confirmed (or in the paper record if applicable). • IN PLACE. The Care Programme Approach promotes effective liaison and communication between service users, carers and staff and agencies. • IN PLACE. Our approach reflects the requirements of the Care Act 2014 and also the guiding principles of the Mental Health Act Code of Practice (2015). • UNDERWAY. The Care Programme Approach is being discontinued for Community patients in line with new National Framework, and replaced with flexible Dialogue+ . The Trust is ensuring that noted changes and recommendations are reflected in the replacement policy.
15
The Wells unit
Action Plan Published
Recommendation
The Wells unit must ensure that all patient reported allegations of bullying are appropriately investigated, and safeguarding procedures instigated.
16
The Trust
Accepted
Recommendation
The Trust must ensure that the policy expectations regarding risks to family members are incorporated into risk assessment and care planning.
Review and ensure that policy expectations are incorporated into routine risk assessments and care planning. • COMPLETED. The trust has embedded the Triangle of Care and carers contribute to the collaborative care plans through Care Programme Approach meetings and contact with the clinical team. • COMPLETED. Collaborative care planning is embedded across West London Forensic Services. • IN PLACE. The relevant Trust Policies: C27 Mental Health Clinical Risk and C2 Care Programme Approach & Care Planning address this recommendation, make it clear what is expected from staff • IN PLACE. Plans of care engage the service user and where possible carers and others in considering how best to plan to maximise safety of both the service user and family/carers/members of the public. • IN PLACE. Plans of care/safety outline risk areas including risk to others.
17
The Trust and Local Authority
Accepted
Recommendation
The Trust and Local Authority should complete a review of the current processes in place for identifying children and young people who may be vulnerable to child exploitation, county lines drug gangs or general involvement with gangs to ensure that …
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Undertake a review of existing processes to ensure these follow national best practice • COMPLETED. The Trust policy C18 (Safeguarding Children) was reviewed and re-issued in January 2020. • IN PLACE. Where a child may need Early Help or referral to Children's' Social Care the Trust recommends that consideration should be given to the risk of exploitation and risk of being radicalised or exploited. • IN PLACE. A referral to Children's' Social Care is made when a child is at risk of / known to be a victim of criminal exploitation. • IN PLACE. The Trust safeguarding team are engaged in the Contextual Safeguarding Group with London Borough of Ealing. This is part of a pilot project led by University of Bedfordshire. This has provided the opportunity for the trust to develop a quarterly trust wide contextual safeguarding group facilitated by the Safeguarding Children Advisor and Practice Development Lead (Contextual Safeguarding Champion) and the Local Authority Contextual Safeguarding Team. • IN PLACE. The Trust is actively engaged in Local Authority groups related to child exploitation, county lines and gangs. • IN PLACE. The Local Authoriy maintains close links with colleagues in other authorities and receives support from the University of Bedfordshire. • IN PLACE. Practice is shared and agreed by the Safeguarding Partnership
18
The Trust
Accepted
Recommendation
The Trust must ensure that all families caring for young people in inpatient services are offered access to a carers assessment.
Ensure that carers assessments are offered to all families caring for young people in inpatient services. • COMPLETED. The Trust policy C2 (Care Programme Approach and Care Planning) was reviewed in February 2019 and re-issued in November 2021. • IN PLACE. Clinical teams identify and engage with carers as part of routine clinical practice where possible and offer support when identified in line with the Care Act 2014 requirements, and in line with the principles of the Triangle of Care. • IN PLACE. The Care Programme Approach sets out that the needs of the parent, the children and the family are assessed routinely at each stage of the care pathway. • IN PLACE. Carers are offered an assessment, assessed and provided with a separate care plan detailing required support with their full involvement where they lead the decisions with professional support and in line with the requirements of Care Act 2014 and Triangle of Care. • IN PLACE. The Trust expects staff to address the needs of parents and ensure that they and their children receive support. • IN PLACE. The needs of parents, children and the family are assessed routinely at each stage of the care pathway.
19
The Trust
Accepted
Recommendation
The Trust should assure itself that the perspective of families is included in care planning, and appropriate cultural awareness is applied when communicating with families.
To ensure that families are included in care planning, whilst considering all necessary cultural and social sensitivities and beliefs • COMPLETED. The Trust policy C2 (Care Programme Approach and Care Planning) was reviewed and re-issued in November 2021, to address this. • IN PLACE. Services ensure appropriate information sensitive to race, culture, ethnic origin, gender, asylum and refugee status is available to all service users, and carers/family. • IN PLACE. Services provide the opportunity to discuss information and choices with their Care Co-ordinator/RC or other members of the team. IN PLACE. The Trust Service User and Carer Experience sub committee meet monthly and Community and Recovery Mental Health Services/MINT updates, Acute Mental Health Services updats (including work on Safe Havens) and Trust Wide Forum/We Coproduce are standing items. • IN PLACE. Information is available in a range of languages and accessible formats. • IN PLACE. The Trust has a comprehensive Accessible Information Standards policy. • IN PLACE. There are learning courses for staff including comprehensive Equality and Diversity training. The compliance rate for Equality and Diversity training across the Trust is 92% (Oct '21). • IN PLACE. The Trust Head of Diversity is responsible for providing advice, developing strategy, promoting, and monitoring the overall implementation of diversity and equality within the Trust.
2
The Trust CAMHS service
Accepted
Recommendation
The Trust CAMHS service must ensure that all patients under its care that are subject to CPA have a named care coordinator.
• COMPLETED. The Trust reviewed and strengthened its C2 policy (Care Programme Approach & Care Planning) and it was reissued as a working document in November 2021. The changes include that: a) named care coordinators are required, in order to address how concerns are to be escalated b) there are robust processes relating to safeguarding, and 7 day follow-up, that link with our clinical risk policy c) there are clear expectations for clinical supervision arrangements for care coordinators d) monitoring arrangements and local protocols (including 7 day follow-up procedure) are clear •IN PLACE. All allocated referrals in Child and Adolescent Mental Health Services have a Health Care Professional assigned to them. • IN PLACE. The Responsible Clinicians are responsible for ensuring effective Care Programme Approach processes are embedded into team acceptance and/or admission, review, and discharge arrangements in their respective teams in their service areas. • IN PLACE. The allocation of Care Co-ordinators and cover (due to sickness for example) principles and pathway is clearly outlined in the C2 policy and staff are expected to be fully compliant with this. • IN PLACE. All Care Programme Approach documentation across the Trust is recorded on electronic patient record systems, where used.
20
The Trust
Accepted
Recommendation
The Trust must provide assurance that appropriate accommodation is addressed in all patients’ care planning at the point of discharge from out of area CAMHS forensic admissions.
To provide assurance that appropriate accommodation is addressed in patient's care, based on the Trust Transitions protocol already in place • COMPLETED. The Trust policy C2 (Care Programme Approach and Care Planning) was reviewed and re-issued in November 2021. • IN PLACE. All individuals supported through Care Programme Approach receive a comprehensive mental health assessment, covering health and social care needs, including consideration of appropriate accommodation needs. • COMPLETED. The discharge destination is the responsibility of the discharging provider (as a Trust we no longer provide Child and Adolescent Mental Health Services inpatient services), but we ensure that the adequacy of the accommodation is monitored through our ongoing engagement with the client (Care Programme Approach approach/policy) and we highlight any risks with the responsible bodies (Clinical Governance Group and Local Authority) for resolution.
21
The Trust
Accepted
Recommendation
The Trust must ensure that there are effective processes in place for working with the local authority to meet the accommodation needs of young people with mental health problems.
To agree a safe and effective protocol with the Local Authority, that supports young people in meeting their accommodation needs • The Trust recognises the critical importance that this takes in the care of young people, and acknowledges that further work is required between the agencies. • IN PLACE. Where a panel application in support of a proposed care plan is to be made to the Local Authority, it is accompanied by a thorough and comprehensive Care Assessment in accordance with the current Care Act processes in each borough. • IN PLACE. When planning for discharge clinicians consider the requirements of Chapter 33 of the Code of Practice, which deals with aftercare provisions. • IN PLACE. Where a Tribunal or hospital managers’ hearing has been arranged for a service user who might be entitled to after-care under s117 of the Act, the hospital managers ensure that the relevant Clinical Governance Group and local authority have been informed. • IN PLACE. The Trust has strong s75 (local commissioning arrangements) partnership arrangements with our 3 Local Authorities, which provide a forum for escalation and discussion of these issues at Partnership Boards in all three boroughs. • IN PLACE. Practice is shared and agreed by the Safeguarding Partnership
22
The Trust
Partially Accepted
Recommendation
The Trust to review its existing management of investigations against the requirements of the NHS England SIF, and develop and implement a methodology for the management of investigations that meets the requirements of the NHS England SIF.
Conduct a review of the Trust's management of investigations and compliance with the NHS England SI Framework, and adopt a robust process to address any gaps identified. This should include elements of Duty of Candour, quality of SI reviews, strength of recommendations and performance of completions. • PARTIALLY COMPLETED. The Trust policy I8 (Incident Reporting Management) was reviewed, strengthened and re-issued in January 2020; however, due to Covid-19 pandemic the Trust recognises that further time is required to embed the processes in full. • IN PLACE. The performance of Trust investigations is reviewed monthly at Clinical Service Unit level, as part of the Clinical Improvement Groups or Senior Management Teams. • IN PLACE. Performance of incident reviews is reviewed by the Trust Clinical Governance Group and Quality Committee on a quarterly basis. • IN PLACE. The monthly Trust Patient Safety Group (PSG) has been established, coordinates regular reviews of the quality of investigations and provides recommendations to be actioned by Trust Service Lines. • COMPLETED. An internal audit of Serious Incident reporting and review processes was conducted by RSM Risk Assurance Services LLP in January/February 2021 and found that the Trust had a robust and appropriate process for declaring, investigating and learning from serious incidents. Key Findings from the audit have been used to direct further work. • COMPLETED. An independent review of learning from Trust incidents was undertaken in October 2017 and this has formed the basis of improvement work that has taken place across the Trust.
23
The North West London Collaborative of CCGs
Accepted
Recommendation
The North West London Collaborative of CCGs should revise the CWHHE Serious Incident Operational Policy (November 2016) against the requirements of the NHS England SIF to ensure that it meets with national policy and guidance with regard to the monitoring …
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The CCG has reviewed the North West London CCG Serious Incident Reporting Policy and Procedure and has ensured that it reflects the NHSE Serious Incident Framework(SiF) around the monitoring of action plans. The revised policy reflects the NHSE SiF on the criteria that must be met before an incident can be closed on StEIS (Transfer of Strategic Executive Information System). The updated NWL CCG Serious Incident Report Policy( June 2021) has been approved by the Quality and Performance Committee (NWL CCG) in June 2021
3
The Trust
Accepted
Recommendation
The Trust must revise the EIP Zoning Policy to more clearly define the care and treatment that a patient in the red zone can expect, to support a more assertive approach.
• COMPLETED. The Trust policy was reviewed and re-issued in May 2020. • IN PLACE. The medical team will see clients sooner as an emergency review when they present in crisis, whether clients are identified as red, amber or green zone outside of stipulated treatment time. • IN PLACE. Red Zone clients are reviewed outside of the 3 week medical review period thus responding to the client needs earlier, to mitigate against any potential risk. • IN PLACE. Care Coordinators conduct face to face contacts with at least 3-4 clients per day and the Red Zone clients are managed with 3 attempted contacts in a week with one been face to face, which is reviewed at the weekly team meeting for MDT discussion and formulation of risk. • IN PLACE. All discussions are documented in the Zoning Meeting spreadsheet and entered on the patient’s electronic medical records. • IN PLACE. All clients are under a MDT 8 week formulation assessment where a structured meeting is held with the MDT and the Clinical Summary Portal on RIO is updated in line with the findings. • IN PLACE. Care Plans are reviewed and updated with the client and there is an assertive management approach of clients
4
The Trust
Accepted
Recommendation
The Trust should develop a performance matrix to monitor and improve compliance with the Trust CPA policy, and this matrix must identify patients who have transferred between services and if a CPA was completed.
UNDERWAY. The Trust recognises the importance and need for this, and work is underway to complete this action and ensure comprehensive reporting via a regular and enhanced performance matrix, containing reliable and valid data, with agreed targets. UNDERWAY. A substantial transition component is being implemented to reconcile and merge existing databases into new reporting formats and templates
5
The Trust
Accepted
Recommendation
The Trust must revise the current arrangements to ensure that missed depots are reported to the care coordinator within 48 hours and what plans need to be put in place to provide the missed depot.
Although it is often the Care Coordinator who administers the Depot, the Trust recognises that further work is required to agree the process and associated actions if a patient misses administration. This includes circumstances where other agencies may be involved. • TO DO. Complete a review of current practice in different circumstances and services • TO DO. Agree a robust process where interface challenges may arise in line with 5 and 6. To conduct a review of current depot review of exiting policies (eg. Did Not Attend / Missed Appointment) • IN PLACE. A specific CAMHS Lead role has been established • IN PLACE. Early Intervention in Psychosis support is now extended to include young children. • UNDERWAY. Embedding the Transitions protocol across all relevant services (IN PLACE across CAMHS services)
6
The Trust
Accepted
Recommendation
The Trust must ensure that there is a clear and transparent process in place that will support all patients to be provided with a depot, irrespective of the team providing care and treatment. These arrangements must identify the criteria for …
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Although it is often the Care Coordinator who administers the Depot, the Trust recognises that further work is required to agree the process and associated actions if a patient misses administration. This includes circumstances where other agencies may be involved. • TO DO. Complete a review of current practice in different circumstances and services • TO DO. Agree a robust process where interface challenges may arise in line with 5 and 6. To conduct a review of current depot review of exiting policies (eg. Did Not Attend / Missed Appointment) • IN PLACE. A specific CAMHS Lead role has been established • IN PLACE. Early Intervention in Psychosis support is now extended to include young children. • UNDERWAY. Embedding the Transitions protocol across all relevant services (IN PLACE across CAMHS services)
7
Trust
Accepted
Recommendation
Trust medicine management policies for long acting antipsychotic injections should provide guidance for their use in young people.
To ensure that guidance is provided for the use of long acting antipsychotic injections in young people. • IN PLACE. An internal Off Label Medications process (Reference A14P) is followed across the Trust and is monitored, as outlined in the Trust M2 policy (Medicines Management). • IN PLACE. The Trust also uses the Maudsey Prescribing Guidance and guidelines issued by the Royal College of Psychiatrists.
8
The Trust
Accepted
Recommendation
The Trust to review the approach that it takes to young people with established substance misuse issues and to develop a dual diagnosis approach to these patients.
To develop an agreed approach to the support and management of those with a dual diagnosis. • COMPLETED. The Trust Policy D2 (Co-Existing Mental Health and Substance Use) was issued in August 2021. • IN PLACE. The Trust is involved in partnership working with key charities (ARC, RISE, CGL and Turning Point). • IN PLACE. Specialist workers are embedded into teams, and specialist training is provided throughout Local Services. • IN PLACE. Internal training, including Clinical Risk training and Risk Assessment training both feature substance misuse in the syllabus, and staff are expected to complete this. • IN PLACE. The National Dual Diagnosis Programme (National Mental Health Development Unit, Department of Health) have commissioned a group of consultant nurses (PROGRESS) and Coventry University to develop an innovative online awareness raising resource relating to people who have dual diagnosis. The Trust offers this an e-learning programme aimed at clinical staff. • The compliance in Local Services for risk training is 81% (Sept '21) with a target of 90% by the end of March 2022. • IN PLACE. Independent Reports published by NHSE and relating to dual diagnosis are used to inform learning as part of the Trust's Learning Events programme and Learning Framework.
9
The Trust
Accepted
Recommendation
The Trust must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of children and young people.
To provide assurance that transitions involving children and young people between services, follow NICE guidance. • COMPLETED. A new transitions protocol was created and signed off by service line Directors in Local Services. This drives our patient-centred approach. • IN PLACE. A Task and Finish Group has been set up to implement this new policy across services. • COMPLETED. An audit was undertaken relating to compliance with the NICE guidelines, and actions are being used to inform the current 18-25 Mental Health Integrated Network Teams pathway development. • UNDERWAY. The Trust has continued further work during 2021/22,and through Children and Young People's Transformation funds has focused on age specific services for those aged 16-25.
National recommendat
NHS England & NHS Improvement
Action Plan Published
Recommendation
NHS England & NHS Improvement should work with NICE to consider including in existing guidance information about the prescribing of injectable anti-psychotics for the treatment of psychosis in under 18s.
Regional recommendat
The North West London Integrated Care System
Action Plan Published
Recommendation
The North West London Integrated Care System to seek assurance that all planning for care leavers discharged from mental health in-patient services formally involves the relevant local authority. Furthermore, to seek assurance that the application of Section 117 Mental Health …
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Regional recommendat
The North West London Integrated Care System
Action Plan Published
Recommendation
The North West London Integrated Care System should seek assurance that an understanding of the risks to vulnerable young people of ‘county lines’, and gang related threats is embedded in all services and systems dealing with the mental health of …
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